In January I took part in an author’s panel at a New York aeronautical college; we discussed our books – in my case, a novel – and talked about the industry’s future. One student asked about why recommendations aren’t more strictly enforced. I explained, using examples of similar accidents occurring under related causes, why recommendations are repeated. I said, “Recommendations aren’t enforceable. We’re duplicating our mistakes, ignoring lessons of accidents past. In other words, we are not learning.”
Ron Donner emailed me an article from The Daily Telegraph, a British daily newspaper; he asked me what I thought of the story. My original notion was: Ron and I have known each other for years; he should know better than to ask my opinion on … anything.
The article was on British Airways flight BA762, an Airbus A319-131 that took off from – and immediately returned to – Heathrow airport on May 24, 2013; its short flight due to the separation of both engines’ fan cowls during take-off roll; that amounts to four cowls departing the aircraft simultaneously. The fleeing cowls damaged the #2 engine’s fuel line, resulting in an inflight fire.
A lesser point: the unnamed Telegraph writer was naïve, naming phantom issues that the report never mentioned. Why’s this problematic? Average people don’t read accident reports, instead relying on news articles. Asiana 214, Malaysia Air MH370, Germanwings 9525, etc. played out for weeks in the media; daily news accounts brimming with allegations and opinion – not facts. It’s like comedian Steve Martin said, “Do you want to mess with your child? Teach him how to speak wrong.” We end up with an uninformed public who can’t trust technicians and pilots. It’s also why aeronautical students don’t understand why recommendations don’t work.
The greater point: I referred to the original Air Accidents Investigation Branch (AAIB) report on the incident: Special Bulletin (SB) S3/2013, published Dec. 10, 2014. The AAIB investigates in accordance with Annex 13 of the Convention on International Civil Aviation. Accident reports don’t assign blame; they give accurate event summaries and recommendation(s).
Accident Report
The AAIB report ignored the sensationalistic reporting of the Daily Telegraph; no mention of alarmed passengers, absentminded technicians or fatigue. It detailed the airliner’s damage following the fan cowls’ departures; the harm was extensive, as can be expected, but fortunately not enough to threaten its safe landing.
The report reminded me of the student’s question: why aren’t recommendations more strictly enforced? In SB S3/2013, the AAIB wrote Safety Recommendation 2013-011: “… that Airbus formally notifies operators of A320-family aircraft of the fan cowl door loss … reiterates the importance of verifying that the fan cowl doors are latched prior to flight … latches.” This impotent recommendation did nothing; the lessons learned amounted to nothing; air safety gained nothing.
The AAIB said the A319-131 was fresh out of maintenance; Flight BA762 was its first flight. We’re led to believe the pre-flight was uneventful … except for the simple fact several people failed to notice the open engine cowls. The AAIB recommendation: send a memo to mechanics saying, essentially: Close all cowls before flight.
I’m not making this up.
Safety Recommendations
Not to be outdone, the European Aviation Safety Agency (EASA) distributed Safety Information Bulletin #2015-15 on Aug. 31, 2015. In addition to ambiguously pointing to alleged similar behavior by ‘several operators’, EASA wrote two recommendations (summarized): (1) all operators should amend pre-take-off procedures to alert pilots about open cowls, and, (2) amend the cowl opening/closing procedures. Again, not making this up.
An unlatched wing engine fan cowl doesn’t sit snug against the engine; its center-of-gravity dictates it hangs noticeably away from the engine, visibly making the engine ‘bulge’ when seen from the front or back. The latches aren’t recessed; they hang straight down and are obvious from the side. Since “nothing unusual” occurred during pre-flight, how did the first officer miss four open engine cowls during his/her preflight walk-around on this aircraft’s first-flight-of-the-day in broad daylight? There’s also no mention in either report of whether or not the crew reviewed the logbook to assure all maintenance items were signed off. I could make at least five recommendations just on the Operations side and another six for the Airworthiness side, from training to revisions for both General Manuals.
It is vital to identify stark critical errors in both maintenance and operations; in this case, unlocked engine cowls proved to be one problem. But accident/incident investigation doesn’t stop there because the real cause is always below the surface; that’s where the AAIB and EASA fell on their swords; they punted on first down.
Maintenance Factor
What were the cultural anomalies for Maintenance and Operations at British Airways or even the ‘several operators’ that have seen this problem? This was not an accident, yet the seriousness of the incident demands a thorough review, one where the findings will proactively prevent a recurrence. Either the investigators chose to overlook important discrepancies or they were unfamiliar with how all divisions in an airline work.
Before 2001, the NTSB did not have FAA-certificated aircraft maintenance accident investigators; maintenance issues were delegated to engineers who never turned a wrench. I was hired into the NTSB because (former) Member John Goglia demanded they employ an FAA-certificated A&P technician/investigator who not only understood maintenance/engineering issues, e.g. task cards or poorly written manual instructions; but had good exposure to the day-to-day problems facing certificate holders, specifically an airline. He understood that every certificate holder, from Mom and Pop repair stations to international airlines, have cultures. As a result these cultures can raise safety concerns.
When I’d interview mechanics after an accident, my goal was to ascertain the conditions of the job, e.g. employee shifts, flight schedules. These gave clear insight into other factors affecting safety. It’s obvious to me the AAIB and EASA lack this important insight.
Until accident investigation organizations take the role of maintenance as a serious contributor to safety, occasions to improve the safety culture in all transportation modes will become lost opportunities and aeronautical students will continue to ask, “Why?”
